Company OverviewCohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient's healthcare experience, both in and out of the doctors office. Founded in August, 2019, we are obsessed with eliminating wasteful friction patients and doctors experience in areas that have nothing to do with health and treatment, particularly for diagnoses that require expensive procedures or medications. To that end, we build software that is expressly designed to ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles.Opportunity Overview: The RN Reviewer position is a crucial role in our organization — in this role you are responsible for performing a full range of activities that will positively impact the organization and contribute to guiding the strategic operations for the company. As an RN Reviewer, you will perform prospective review (prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. You will work closely with Medical Directors and other Cohere Health staff to ensure appropriate cost-effective care by applying your clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, and provider out of network requests. You will be required to review Commercial, Medicare, and Medicaid lines of business.You will need to be an agile and comprehensive thinker and planner and be able to work in an environment that is in flux. This position offers the ability to make a substantive mark in simplifying the way healthcare is delivered and contributes to an up and coming company with exponential growth opportunity.Last but not least: People who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles . We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone.What will you doPerforms medical necessity review which includes: inpatient review, concurrent review, prior authorization, retrospective, out of network, treatment setting reviews to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefitsConsults with Medical Directors when care does not meet applicable criteria or medical policiesDocuments clinical information completely, accurately, and in a timely mannerMeets or exceeds production and quality metricsMaintains a thorough understanding of the Cohere Health's provider and member centric focus, authorization requirements and clinical criteria including MCG care guidelines and Cohere Health's internal criteria, and National and Local coverage guidelinesIdentifies Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)Collaborates, educates, and consults with Providers, Operations, Product, Implementation, Compliance, Quality, and Health Plans to ensure consistent application of clinical criteria as well as promote the CarePath concept to ensure optimal patient outcomeMaintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within complianceSupports the Plan'sQuality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projectsPerforms other duties as assigned.Your competenciesStrong customer service skillsFlexibility and agility, work well in ambiguous situations, clear understanding of an early stage start up environmentAbility to work cross functionally across remote teamsCollaborate effectively with multiple stakeholdersIntellectual curiosity with a strong desire to understand a problem and work it to a viable solutionStrong communication skills, able to effectively communicate in a positive and engaging manner and able to remain calm and professional under pressureUnderstand how utilization management and case management programs integrateComprehensive thinker/planner with understanding of clinical algorithms, care pathways, and how to effectively manage utilization across the care continuum to achieve optimal patient outcomesAbility to work as a team player and assist other members of the UM team where neededThrive in a fast paced, self-directed environmentKnowledge of NCQA and CMS standards and requirementsProficient user of MCG guidelines, Care Web QI user a plusHighly organized with excellent time management skillsYour backgroundRegistered Nurse with active, unencumbered license in the state of residenceMinimum of 3 years of clinical experience.Utilization Management experience (Required)Experience working in acute care and/or post-acute care environmentsHEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience (Preferred)Preferred proficiency in using a MacPreferred proficiency in G suite applicationsDemonstrated track record of continuous quality improvement Excellent communication skills both written and oralThrives on continuous process improvement, always actively seeking out practical solutions Understanding that this position is very fluid and the term "not my job" doesn't existBachelor's degree (preferred) but not required in the following fields; Nursing, Business, or equivalent professional work experienceImportant to know about this role:This is a 100% remote role, and requires robust internet speeds (above 50 megabytes/second), including the ability to utilize zoom meeting software and to stream videoWe can't wait to learn more about you and meet you at Cohere Health!Equal Opportunity Statement Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it's personalThe salary range for this position is $32.00 to $35.00 hourly; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment.#LI-Remote#BI-Remote
